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Comparison of the 5-Year Outcomes Between Standard and Short Fit-and-Fill Stems in Japanese Populations

Open AccessPublished:April 25, 2022DOI:https://doi.org/10.1016/j.artd.2022.03.023

      Abstract

      Background

      Fit-and-fill stems are known to have excellent outcomes; however, severe stress shielding has been reported in Japanese populations. Short fit-and-fill stems were modified for Asians; however, there have been no previous reports of its outcome. In this study, we compared the 5-year (mean 68-month) outcomes of 2 fit-and-fill stems with different lengths (standard or short).

      Material and methods

      We reviewed 100 total hip arthroplasties in each standard- or short-stem group. Radiographs were evaluated for femoral morphology, stress shielding, bone remodeling, and fixation. Clinical evaluation was performed using the Japanese Orthopaedic Association (JOA) scores.

      Results

      There was no difference in the degree of stress shielding between the 2 groups. Significant differences were observed in radiolucent lines in zone 4 (P = .005) and cortical hypertrophy in zone 3 (P < .0001) and 5 (P = .048) between the 2 groups. The canal flare index (P < .0003), cortical index (P < .0003), height (P < .0345), and stem size (P < .0081) individually affected stress shielding in the standard-stem group. In contrast, the cortical index (P < .0107) was the only relative factor in the short-stem group. All stems were judged to have bone ingrowth. The JOA score improved significantly (P < .0001); however, there were no significant differences between the 2 groups.

      Conclusion

      The outcomes of both standard and short fit-and-fill stems were favorable. There were no significant differences in the stress shielding or JOA scores. Although there were a few differences in bone remodeling and factors affecting stress shielding, stem length reduction has been achieved without adverse effects with the Japanese femur.

      Keywords

      Introduction

      Cementless stems have been widely used in total hip arthroplasty (THA) for decades, and their long-term results have been successful [
      • Belmont Jr., P.J.
      • Powers C.C.
      • Beykirch S.E.
      • et al.
      Results of the anatomic medullary locking total hip arthroplasty at a minimum of twenty years. A concise follow-up of previous reports.
      ,
      • Lombardi Jr., A.V.
      • Berend K.R.
      • Mallory T.H.
      • Skeels M.D.
      • Adams J.B.
      Survivorship of 2000 tapered titanium porous plasma-sprayed femoral components.
      ,
      • Capello W.N.
      • D’Antonio J.A.
      • Jaffe W.L.
      • et al.
      Hydroxyapatite-coated femoral components: 15-year minimum followup.
      ]. In Japan, various foreign-made implants have been introduced and used, and most of them function well. However, there is concern that some of these implants do not match the morphology of the Asian bone due to their smaller skeleton size and greater femoral bowing [
      • Zengin A.
      • Pye S.R.
      • Cook M.J.
      • et al.
      Ethnic differences in bone geometry between White, Black and South Asian men in the UK.
      ,
      • Abdelaal A.H.K.
      • Yamamoto N.
      • Hayashi K.
      • et al.
      Radiological assessment of the femoral bowing in Japanese population.
      ].
      Fit-and-fill stems are known for their excellent stability and low frequency of thigh pain postoperatively [
      • De Martino I.
      • De Santis V.
      • D’Apolito R.
      • et al.
      The Synergy cementless femoral stem in primary total hip arthroplasty at a minimum follow-up of 15 years.
      ,
      • Danesh-Clough T.
      • Bourne R.B.
      • Rorabeck C.H.
      • McCalden R.
      The mid-term results of a dual offset uncemented stem for total hip arthroplasty.
      ,
      • Dikmen G.
      • Ozden V.E.
      • Beksac B.
      • Tozun I.R.
      Dual offset metaphyseal-filling stems in primary total hip arthroplasty in dysplastic hips after a minimum follow-up of ten years.
      ,
      • Panichkul P.
      • McCalden R.W.
      • MacDonald S.J.
      • Somerville L.E.
      • Naudie D.N.
      Minimum 15-year results of a dual-offset uncemented femoral stem in total hip arthroplasty.
      ]. However, severe and progressive stress shielding has been reported in the Japanese population [
      • Nishino T.
      • Mishima H.
      • Miyakawa S.
      • Kawamura H.
      • Ochiai N.
      Midterm results of the Synergy cementless tapered stem: stress shielding and bone quality.
      ,
      • Nishino T.
      • Mishima H.
      • Kawamura H.
      • et al.
      Follow-up results of 10–12 years after total hip arthroplasty using cementless tapered stem – frequency of severe stress shielding with synergy stem in Japanese patients.
      ]. Fit-and-fill stems are used at our institution, and in 2013, we began to utilize the modified shorter model of the same series to conform to the Asian femur. There are no previous reports comparing standard and short fit-and-fill stems, and the benefit of this modification is still unclear. The purpose of this study was to describe the differences between these 2 implants using retrospective radiographic and clinical results in Japanese populations.

      Material and methods

      Implants

      The Synergy (Smith and Nephew, Memphis, TN; hereinafter referred to as “original stem”) stem is a double-tapered metaphyseal filling stem made of a titanium alloy (Ti-6Al-4V). The stem has a rough titanium bead porous coating on the proximal third and is grit-blasted below the proximal third to a point near the end. The distal part of the stem is bullet-shaped and polished. The trunnion diameter is 12/14. The Synergy Select stem (Smith and Nephew, Memphis, TN; hereinafter referred to as “standard stem”) is a minor variation of the same series. The trunnion diameter was changed to 10/12 to maximize the oscillation angle. The stem body design is the same as that of the original stem. The Synergy Select 2 stem (Smith and Nephew, Memphis, TN; hereinafter referred to as “short stem”) is a stem modified to fit the Asian femur. The length of the short stem is 15 mm shorter than that of the standard stem, and the coating and stem proportions are the same. The radiographs of the implants of the same size are shown in Figure 1. All implants were combined with a Reflection (Smith and Nephew, Memphis, TN) cup and OXINIUM (Smith and Nephew, Memphis, TN) head.
      Figure thumbnail gr1
      Figure 1Radiographs of the (a) standard stem and (b) short stem (size 12).

      Patients

      We retrospectively reviewed the records of patients who underwent THA at our hospital. Since the standard stem was used until December 2012, we traced 100 hip arthroplasty cases whose radiographs were available at the second (24–35 months) and fifth year (60–71 months) postoperative intervals. A total of 131 THAs with the standard stem were performed between December 2011 and December 2012, with clinical questionnaire scores of 79 cases at the second and fifth year available. The short stem was used from January 2013, and we traced 100 cases that had radiographs available at the second and fifth year postoperative intervals. A total of 132 THAs with the short stem were performed between January 2013 and December 2013, and the clinical questionnaire scores of 88 cases at the second and fifth year were available. The study flowchart is shown in Figure 2. Patients whose records were not available were excluded at each radiographic or clinical evaluation. The protocol of this retrospective study was approved by the institutional review board of our hospital. Informed consent for the study was obtained using the opt-out method via our hospital website.

      Operative procedure

      Surgeries were performed using the posterior approach by 8 orthopedic surgeons. The implants were inserted by manual reaming and broaching using standard instruments. All patients were encouraged to ambulate and were allowed full weight-bearing on the first postoperative day. Rehabilitation was performed by physical therapists at the department of rehabilitation in our hospital, according to each patient's progress. Patients were given cefazolin sodium infusion (3 times on the day of operation, 1000 mg each) as a standard antibiotic prophylaxis and subcutaneous injection of enoxaparin sodium (2000IU twice daily for 2 weeks) to prevent thrombosis.

      Radiographic assessments

      Anteroposterior radiographs were obtained in the supine position. Radiographic measurements were performed by a single observer (author S.K.) who was not involved in the surgery. The ruler function of the electronic medical record system (HOPE Dr ABLE-GX V01; Fujitsu, Japan) was used for digital analysis.
      The femoral morphology was evaluated using the preoperative radiographs. The cortical index (CI) [
      • Dorr L.D.
      • Faugere M.C.
      • Mackel A.M.
      • et al.
      Structural and cellular assessment of bone quality of proximal femur.
      ], canal-calcar ratio [
      • Dorr L.D.
      • Faugere M.C.
      • Mackel A.M.
      • et al.
      Structural and cellular assessment of bone quality of proximal femur.
      ], and canal flare index (CFI) [
      • Noble P.C.
      • Alexander J.W.
      • Lindahl L.J.
      • et al.
      The anatomic basis of femoral component design.
      ] were analyzed.
      Radiographs at the second and fifth year were used to evaluate postoperative outcomes. Stress shielding was classified based on Engh's classification [
      • Engh C.A.
      • Engh C.A.
      • Bobyn J.D.
      • Glassman A.H.
      Porous-coated hip replacement. The factors governing bone ingrowth, stress shielding, and clinical results.
      ]. Radiolucent lines, cortical hypertrophy, and spot welds were recorded using the Gruen zones [
      • Gruen T.A.
      • McNeice G.M.
      • Amstutz H.C.
      Modes of Failure of cemented stem-type femoral components: a radiographic analysis of loosening.
      ]. Typical radiological changes are shown in Figure 3, Figure 4, Figure 5. A stem subsidence greater than 2 mm was considered to be positive. Stem biological fixation was evaluated according to Engh’s criteria [
      • Engh C.A.
      • Massin P.
      • Suthers K.E.
      Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components.
      ].
      Figure thumbnail gr3
      Figure 3Example of stress shielding observed in standard stem. (a) First degree; (b) second degree; (c) third degree; (d) fourth degree.
      Figure thumbnail gr4
      Figure 4Example of stress shielding observed in short stem. (a) First degree; (b) second degree; (c) third degree; (d) fourth degree.
      Figure thumbnail gr5
      Figure 5Example of radiological changes observed. (a) Radiolucent line in zone 4; (b) cortical hypertrophy in zone 3 and 5; (c) spot welds in zone 3 and 5.

      Clinical evaluation

      Japanese Orthopaedic Association (JOA) scores [
      • Imura S.
      The Japanese Orthopaedic Association: evaluation chart of hip joint functions.
      ] were recorded preoperatively and at the second and fifth years postoperatively. The JOA score consists of 40 points for pain, 20 points for range of motion, 20 points for walking ability, and 20 points for activities of daily living. Thigh pain was considered to be positive when the JOA score for pain was recorded as 30 points (described as “no pain during walking; however, pain at the start of walking or after long-distance walking may occur occasionally”) or less. In addition, complications (dislocations and fractures) found during follow-up were also recorded.

      Statistical analysis

      An unpaired t-test was used to compare continuous variables between the standard- and short-stem groups. Paired t-test was used to compare the JOA scores between each follow-up. Fisher's exact test (for a 2 × 2 table) or Chi-square test was used for categorical variables. Stress shielding was analyzed using the Mann-Whitney test to compare the standard- and short-stem groups, while the Wilcoxon test was used to compare each follow-up. Multiple regression analysis was performed by stepwise selection method that included age, height, body mass index, stem alignment, stem size, CI, canal-calcar ratio, and CFI as independent variables and stress shielding as the dependent variable. Data analysis was performed using Prism 7.04 (GraphPad Software Inc., San Diego, CA) with statistical significance set at P < .05.

      Results

      There were no significant differences in baseline patients’ characteristics between the 2 groups (Table 1). The Wilcoxon test showed significant progression of stress shielding in both groups (P < .0001) from the second to the fifth year (Table 2). However, the degree of stress shielding was not significantly different between the 2 groups in the second (P = .17) and fifth year (P = .53).
      Table 1Patients’ characteristics.
      Patient characteristicsStandard stemShort stemP value
      Age (y)64.0 ± 11.665.2 ± 11.4.45
      Height (cm)156.2 ± 7.7154.9 ± 7.7.24
      BMI22.8 ± 3.123.0 ± 3.6.73
      Gender (n); M:F13:879:91.50
      Operation side (n); R:L53:4755:45.89
      Diagnosis (n)
       OA8887
       ON610
       RA63.37
      Stem size12.3 ± 1.512.2 ± 1.5.47
      Stem alignment
      Varus angle.
      0.86 ± 0.940.97 ± 1.18.48
      Femoral morphology
       Cortical index0.52 ± 0.060.52 ± 0.06.68
       Canal-to-calcar ratio0.62 ± 0.070.64 ± 0.08.09
       Canal flare index3.54 ± 0.623.58 ± 0.64.67
      BMI, body mass index; OA, osteoarthritis; ON, osteonecrosis; RA, rheumatoid arthritis.
      a Varus angle.
      Table 2Degree of stress shielding analyzed using the Wilcoxon test.
      Degree of stress shieldingStandard stemShort stem
      Second yearFifth yearSecond yearFifth year
      First35201912
      Second53577666
      Third1018421
      Fourth2511
      P value<.0001
      Significant progression of stress shielding from the second to fifth year in both groups is observed.
      <.0001
      Significant progression of stress shielding from the second to fifth year in both groups is observed.
      a Significant progression of stress shielding from the second to fifth year in both groups is observed.
      The number of radiolucent lines, cortical hypertrophy, and spot welds are shown in Table 3. Significant differences were observed in radiolucent lines in zone 4 between the 2 groups (P = .005) at the second year follow-up. Similarly, there were significant differences in the amount of cortical hypertrophy between the 2 groups in zone 3 at the second (P < .0001) and fifth year (P < .0001) and in zone 5 at the fifth year (P = .048). The presence of any distal bone fixation (cortical hypertrophy or spot welds in zone 3 or 5) had a significant relationship with severe (third or fourth degree) stress shielding in both standard- (P = .0061) and short-stem (P = .0055) groups at the fifth year (Table 4).
      Table 3Amount of bone remodeling per the Gruen zone observed at the second and fifth year.
      Follow-upGruen zoneStandard stemShort stem
      Radiolucent linesCortical hypertrophySpot weldsRadiolucent linesCortical hypertrophySpot welds
      Second year1600702
      2001102
      3061503213
      41001110
      50164722836
      6002001
      7000000
      Fifth year1201413
      2001003
      3092703819
      4100620
      50185913149
      6001003
      7000000
      Table 4Results of Fisher's exact test performed with availability of distal bone fixation (cortical hypertrophy or spot welds in zone 3 or 5) and severity of stress shielding.
      Standard stemShort stem
      Second yearFifth yearSecond yearFifth year
      Mild stress shielding50516858
      Distal bone fixation +
      Mild stress shielding38262720
      Distal bone fixation −
      Severe stress shielding922522
      Distal bone fixation +
      Severe stress shielding3100
      Distal bone fixation −
      P value0.350.0061
      Statistically significant.
      0.320.0055
      Statistically significant.
      +, positive; −, negative.
      a Statistically significant.
      Multiple regression analysis revealed a significant relationship between stress shielding and the CFI, CI, height, and stem size in the standard-stem group although the CI was the only factor that affected stress shielding in the short-stem group (Table 5).
      Table 5Multiple regression analysis performed to indicate factors that affect stress shielding.
      Follow-upIndependent variablesStandard stemShort stem
      Estimated value95% Confidence intervalP valueEstimated value95% Confidence intervalP value
      Second yearIntercept4.04861.0141 to 7.0830.00953.41221.1045 to 5.7199.0042
      Canal flare index0.43360.1754 to 0.6919.0012
      Statistically significant.
      0.1112−0.0802 to 0.3025.2516
      Cortical index−4.4513−7.1757 to −1.7269.0016
      Statistically significant.
      −3.9105−6.2509 to −1.5700.0013
      Statistically significant.
      Height−0.0238−0.0394 to −0.0081.0034
      Statistically significant.
      0.0023−0.0119 to 0.0164.7484
      Stem size0.18130.0691 to 0.2935.0018
      Statistically significant.
      −0.022−0.1165 to 0.0725.6446
      Fifth yearIntercept3.950.6085 to 7.2916.0214.19771.4736 to 6.9219.0029
      Canal flare index0.54240.2580 to 0.8267.0003
      Statistically significant.
      0.1427−0.0832 to 0.3686.2128
      Cortical index−5.6699−8.6700 to −2.6698.0003
      Statistically significant.
      −3.6244−6.3872 to −0.8615.0107
      Statistically significant.
      Height−0.0186−0.0359 to −0.0014.0345
      Statistically significant.
      −0.0088−0.0255 to 0.0079.3000
      Stem size0.16840.0449 to 0.2919.0081
      Statistically significant.
      0.0523−0.0593 to 0.1638.3547
      CI, cortical index.
      a Statistically significant.
      One stem subsidence was recorded in the standard-stem group. All stems in both groups were considered to have bone ingrowth.
      There were no significant differences in the JOA scores between the 2 groups (Table 6). The total and subsection scores of the JOA significantly improved after surgery (P < .0001). The prevalence of thigh pain in the standard-stem group was 2.4% at the second year and 3.5% at the fifth year. Similarly, in the short-stem group, 3.2% and 4.2% of patients expressed thigh pain at the second and fifth year, respectively.
      Table 6Results of clinical outcomes.
      Follow-upJOA scoreStandard stemShort stemP value
      PreoperativePain15.6 ± 5.915.6 ± 5.6.94
      ROM13.0 ± 3.212.4 ± 3.4.31
      Walking ability9.4 ± 3.19.1 ± 3.6.52
      ADL12.7 ± 2.512.0 ± 3.0.08
      Total50.7 ± 9.649.0 ± 11.2.30
      Second yearPain38.5 ± 2.438.4 ± 2.7.75
      ROM16.2 ± 2.615.9 ± 2.0.32
      Walking ability16.5 ± 3.716.5 ± 3.6.94
      ADL17.0 ± 2.617.1 ± 2.4.98
      Total88.3 ± 8.287.8 ± 7.5.66
      Fifth yearPain38.7 ± 2.538.7 ± 2.7.92
      ROM16.4 ± 2.516.2 ± 2.1.51
      Walking ability16.9 ± 3.516.7 ± 3.8.72
      ADL17.3 ± 2.617.2 ± 2.5.83
      Total89.3 ± 8.588.7 ± 8.1.66
      ADL, activities of daily living; ROM, range of motion.
      Dislocation was recorded in 3 patients in the standard-stem group and in 2 patients in the short-stem group. One patient in the standard-stem group required revision surgery of the polyethylene liner and head due to recurrent dislocation. The other 4 patients had no repeated dislocation. One case of postoperative fracture occurred in each group and were treated by internal fixation operation using a periprosthetic femoral fracture plate. Therefore, no patient required stem revision during follow-up.

      Discussion

      The midterm clinical and radiological results with standard and short stems were favorable. No stem showed aseptic loosening, and the JOA score improved significantly. Several reports [
      • De Martino I.
      • De Santis V.
      • D’Apolito R.
      • et al.
      The Synergy cementless femoral stem in primary total hip arthroplasty at a minimum follow-up of 15 years.
      ,
      • Danesh-Clough T.
      • Bourne R.B.
      • Rorabeck C.H.
      • McCalden R.
      The mid-term results of a dual offset uncemented stem for total hip arthroplasty.
      ,
      • Dikmen G.
      • Ozden V.E.
      • Beksac B.
      • Tozun I.R.
      Dual offset metaphyseal-filling stems in primary total hip arthroplasty in dysplastic hips after a minimum follow-up of ten years.
      ,
      • Panichkul P.
      • McCalden R.W.
      • MacDonald S.J.
      • Somerville L.E.
      • Naudie D.N.
      Minimum 15-year results of a dual-offset uncemented femoral stem in total hip arthroplasty.
      ] show the excellent survivorship of fit-and-fill stems, and the outcomes of our study regarding the short-stem variation are in keeping with the results of these reports. Unfortunately, the severity of stress shielding in the mid-term results of our study was similar to that of a previous report [
      • Nishino T.
      • Mishima H.
      • Miyakawa S.
      • Kawamura H.
      • Ochiai N.
      Midterm results of the Synergy cementless tapered stem: stress shielding and bone quality.
      ] in the Japanese population. In addition, a following report [
      • Nishino T.
      • Mishima H.
      • Kawamura H.
      • et al.
      Follow-up results of 10–12 years after total hip arthroplasty using cementless tapered stem – frequency of severe stress shielding with synergy stem in Japanese patients.
      ] by the same author mentions progressive stress shielding in the long-term results. Although these 2 reports are results of the original stem, there are concerns that standard and short stems may have the same trend of stress shielding.
      The review of the multiple regression analysis results of standard stems, femoral morphology, height, and stem size showed individual effects on stress shielding. If the use of a standard stem is planned, it may be too complicated to estimate stress shielding in the future. Some reports [
      • Zengin A.
      • Pye S.R.
      • Cook M.J.
      • et al.
      Ethnic differences in bone geometry between White, Black and South Asian men in the UK.
      ,
      • Abdelaal A.H.K.
      • Yamamoto N.
      • Hayashi K.
      • et al.
      Radiological assessment of the femoral bowing in Japanese population.
      ] have shown that Asians have a smaller skeleton size, greater femoral bowing, and thinner femoral cortices. We believe that the mismatch between the Japanese femur and the standard stem leads to complications, such as increased stress shielding. In contrast, the results of using the short stem show that only the CI has a significant effect, as low CI (thin femur bone cortex) leads to severe stress shielding. In terms of predicting stress shielding, the short stem can be used easily for the Asian femur because less factors need to be considered.
      There was no significant difference between the degree of stress shielding of the 2 groups although a high frequency of cortical hypertrophy was observed in zones 3 and 5 in the short-stem group. Comparing standard and short stem, the diameter of the short stem reduces faster as you go distal. Therefore, the strain in zones 3 and 5 should be greater in the short-stem group. Distal cortical hypertrophy is said to be a result of abnormal bone strain; however, its influence on outcomes is controversial [
      • Ritter M.A.
      • Fechtman R.W.
      Distal cortical hypertrophy following total hip arthroplasty.
      ,
      • Whiteside L.A.
      The effect of stem fit on bone hypertrophy and pain relief in cementless total hip arthroplasty.
      ,
      • Cho Y.J.
      • Chun Y.S.
      • Rhyu K.H.
      • Baek J.H.
      • Liang H.
      Distal femoral cortical hypertrophy after hip arthroplasty using a cementless double tapered femoral stem.
      ]. In our study, distal cortical hypertrophy had no significant impact on stress shielding or thigh pain. Since there were no complications associated with this process, it is difficult to judge whether it is a positive or negative change; therefore, further research is required. At least up to the fifth year, stem length reduction has been achieved without adverse effects. The advantage of this is that for revision surgery, easier implant removal and more preserved bone stock can be expected.
      Regarding the concept of a fit-and-fill stem that better matches the Asian femur, a report [
      • Small S.R.
      • Hensley S.E.
      • Cook P.L.
      • et al.
      Characterization of femoral component initial stability and cortical strain in a reduced stem-length design.
      ] discusses the idea of further shortened stems. Although there are few differences in the intended design, they hypothesize that even shorter stems can achieve physiological femoral loading without losing stability.
      The main strength of our study is that this is a unique report comparing results between standard and shortened fit-and-fill type stems. Successful results in the Japanese population support a short-length fit-and-fill stem as a reliable implant. However, this study has several limitations. First, a relatively large number of patients (radiographs of 24% in each group, full records of 40% in the standard-stem group and 33% in the short-stem group) were lost to follow-up. This missing value can affect actual results. Fortunately, there were no revision reports or requests for primary surgery information, and it was therefore assumed that most of the patients’ implants are functioning well. Second, radiographs were analyzed by a single observer only, lacking interobserver and intraobserver differences. The accuracy and reproducibility of radiographs have been stated to be unreliable [
      • Engh Jr., C.A.
      • McAuley J.P.
      • Sychterz C.J.
      • Sacco M.E.
      • Engh Sr., C.A.
      The accuracy and reproducibility of radiographic assessment of stress-shielding. A postmortem analysis.
      ]. In addition, due to poor posture reproducibility, assessment of lateral radiographs was not performed. Finally, since this was a retrospective and nonrandomized study, potential bias must also be considered. For instance, surgical skills may have some improvement in the later (short stem) year.

      Conclusions

      The outcomes of both standard and short fit-and-fill stems were favorable. Regarding the degree of stress shielding, there was no significant difference between the 2 stems. However, there were differences in bone remodeling and factors affecting stress shielding. Stem length reduction has been achieved without adverse effects with the Japanese femur; however, long-term follow-up is required.

      Acknowledgments

      The authors would like to thank Editage (www.editage.com) for English language editing.

      Conflicts of interest

      The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: M. Ishijima is in the speakers' bureau of/gave paid presentations for Ono Pharmaceutical Co. Ltd., Pfizer Japan Inc., Taisho Pharmaceutical Holdings, Kaken Pharmaceutical Co. Ltd., and Teijin HealthCare Co. Ltd.; receives research support from Japan Medical Dynamic Marketing (JMDM) Co. Ltd., Olympus Terumo Biomaterials Co. Ltd., Suntory Wellness Co. Ltd., CellSource Co. Ltd., MATHYS Co. Ltd., and Stryker Co. Ltd.; and is a board member in Osteoarthritis Research Society International.
      For full disclosure statements refer to https://doi.org/10.1016/j.artd.2022.03.023.

      Appendix A. Supplementary data

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